Spinal Disorders: Fundamentals of Diagnosis and Treatment Part 112 pps

weight patients are at higher risk [22, 105]. Causal treatment is reduction of the
correction.Thisisusuallynotrequired.Thesymptomswillamelioratewithin
weeks and with intravenous hyperalimentation. In rare cases, duodenojejuno-
stomy will be required.
Urogenital Complications
Urinary Tract Infection
Check for bladder residual
urine
The most frequent urogenital complication is a simple urinary tract infection
(UTI), which can occur in up to 9% of patients [5]. Ascending infection with
pyelonephritis or sepsis is rare. These complications can be minimized when
perioperative catheterization is used only when absolutely indicated. On the
other hand, incomplete bladder emptying also increases the risk of infection.
Ultrasonography is very helpful in estimating the residual urine amount, which
should be less than 100 cc.
Postoperative Anuresis
Check perianal sensation
in postoperative anuresis
In the immediate postoperative period, patients often have difficulty in urinat-
ing. The most frequent cause is the inability to empty the bladder in a lying posi-
tion. However, anal tone and sensation must be controlled to rule out a cauda
equina syndrome. Early mobilization solves this problem. If this is not possible,
catheterization is necessary to avoid bladder overdistension.
Urinary Bladder Dysfunction
Afteranteriorsurgery,abladderdysfunctioncanresultfromaninjurytothe
parasympathetic presacral nerves especially at the level of L5/S1. This complica-
tion can perhaps be reduced by a retroperitoneal approach, where the sympa-
thetic and parasympathetic fibers located close to the peritoneum in the bifurca-
tion of the vessels are left intact [34].
Retrograde Ejaculation
Initial reports have perhaps underestimated the problem. A survey of 20 sur-

geons in 1984 reported 0.42 % retrograde ejaculation and 0.44% impotence fol-
lowing anterior lumbar spine fusion [37]. The more thoroughly studies were
undertaken, the higher (2–4%) was the reported incidence [8, 11, 99]. It seems
that the problem is mainly approach related, with the incidence being much
higher in transperitoneal than in retroperitoneal approaches to the lumbar spine.
This complication is most
likely more common
than reported
Recently,inanteriorlumbarinterbodyfusiontheratewas2%inretroperitoneal
and 13% in transperitoneal cases [99]. A lesion of the hypogastric plexus must be
avoided during approaches to the lumbar spine. The plexus is located in front of
the vessel bifurcation, close to the peritoneum. In transperitoneal approaches,
the plexus is split directly under the peritoneum. Retroperitoneal approaches
allow for preparation behind the vessels, so the plexus can be preserved. The
restrictive use of bipolar cauterization may reduce the risk.
1114 Section Complications
Recapitulation
Frequency of complications.
Complication rates of
spinal procedures are dependent on the type of
surgery, spinal pathology, the experience of the sur-
geon and confounding factors such as age and co-
morbidities. The most frequent complications of
cervical surgery are infection (1.6%) and Horner’s
syndrome (1.1%) as well as neurologic deteriora-
tion (3.3 %) in cervical myelopathy. In anterior spinal
surgery, death and paraplegia are encountered in
0.3–0.4% and 0.2–0.4%, respectively. The overall
complication rate for posterolateral fusion is about
6% and is dependent on the age of the patient. Im-

plant related neurological compromise and post-
operative wound infection are among the most
frequent complications.
Preventive measures. The best treatment for com-
plications is their avoidance. Important measures to
prevent complications are the screening for risk fac-
tors such as past history of thromboembolic com-
plications, previous postsurgical infections, previ-
ous surgery, malnutrition, cardiovascular disease,
COPD, smoking, and medications (e.g., NSAIDs).
Detailed preoperative planning including potential
salvage strategies is mandatory to minimize the risk
of complications. A profound knowledge of the sur-
gical anatomy is indispensable. Correct patient po-
sitioning reduces blood loss. Neuromonitoring is a
must in cases in which deformity correction is at-
tempted.
Approach-related complications. The superior
and recurrent laryngeal nerve and the cervical ar-
teries are at risk when performing an anteromedial
cervical approach. Lung lacerations and injuries to
the thoracic vessels may occur when a thoracotomy
is done. Pulmonary artery lesions are very chal-
lenging to repair even for very experienced thoracic
surgeons. Postoperative pneumothorax and he-
matothorax can be avoided by proper drainage. A
chylothorax can become a life-threatening prob-
lem and requires temporary parenteral nutrition. A
thoraco-lumbar approach may jeopardize the liver
and spleen. Venous and arterial injuries may occur

with abdominal approaches and require adequate
repair and aftertreatment. Bowel and urethral inju-
ries arerarebutmustnotbeoverlooked.
Procedure-related complications. Excessive epi-
dural bleeding is a frequently encountered prob-
lem during posterior decompressive surgery and
can be reduced with correct patient positioning.
Nerve root injuries subsequent to posterior Instru-
mentation can be minimized with proper training
and experience. Unintended durotomy is not infre-
quent in cases with severe spinal canal stenosis,
and direct repair is recommended whenever pos-
sible. Distraction during deformity correction is
prone to neurological compromise and must be
avoided. Hypotensive surgery should be avoided
when correcting severe spinal deformity. Reduc-
tion of high-grade spondylolisthesis jeopardizes
the L5 nerve root and complete reduction should
therefore be avoided.
Postoperative complications. Postoperative moni-
toring must include blood loss, neurological and
vascular status. Continuous postoperative bleed-
ing is a frequent problem particularly after posteri-
or revision surgery and spinal osteotomies. This
problem can be minimized with proper intraopera-
tive hemostasis and timely blood and factor substi-
tution. Persistent wound drainage is indicative of
infection or malnutrition. A hypoliquorrhea syn-
drome only occurs with tiny leaks not discovered
intraoperatively and which most often need to be

repaired. Postoperative vascular complications are
rare but may be detrimental if overlooked, particu-
larly large vessel injuries with continuous bleeding
or arterial thrombosis. Pulmonary complications
can be minimized with proper preoperative respira-
tory treatment. The duration of postoperative
bowel atonia can be reduced by avoiding extensive
opioid treatment and alternatively using postoper-
ative peridural anesthesia. Urinary tract infections
are not infrequent and routine catherization for
short surgeries should be avoided. The rate of retro-
grade ejaculation (2–13%) is more frequent than as-
sumed and can be reduced by avoidance of cauter-
ization of the pre-discal vessels.
Treatment of Postoperative Complications Chapter 39 1115
Key Articles
BaronEM,AlbertTJ(2006) Medical complications of surgical treatment of adult spinal
deformity and how to avoid them. Spine 31:S106 – 18
Recent extensive review of complications in adult spinal surgery.
Bungard TJ, Kale-Pradhan PB (1999)Prokineticagentsforthetreatmentofpostopera-
tive ileus in adults: a review of the literature. Pharmacotherapy 19:416 – 423
A good description of how to treat postoperative bowel atonia. The different pharmaceu-
tical options are discussed.
Coe JD, Arlet V, Donaldson W, Berven S, Hanson DS, Mudiyam R, Perra JH, Shaffrey CI
(2006) Complications in spinal fusion for adolescent idiopathic scoliosis in the new mil-
lennium. A report of the Scoliosis Research Society Morbidity and Mortality Commit-
tee. Spine 31:345 – 9
Review of complications in 6334 patients undergoing surgery for adolescent idiopathic
scoliosis.
FlinnWR,SandagerGP,SilvaMBJr,BenjaminME,CerulloLJ,TaylorM(1996)Prospec-

tive surveillance for perioperative venous thrombosis. Experience in 2 643 patients.
Arch Surg 131:472 – 480
An excellent study of all aspects of thrombosis and pulmonary embolism in spine sur-
gery. The article demonstrates the relatively low risk of venous thrombosis in comparison
to orthopedic procedures like arthroplasty of large joints.
Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L (1995) The surgical and medi-
cal complications of anterior spinal fusion surgery in the thoracic and lumbar spine in
adults. A review of 1 223 procedures. Spine 20:1592 – 1599
This article is a good overview of the incidence of complications of anterior deformity
surgery. The overall estimation of the risk is perhaps too optimistic. Therefore the article
by Leung and Grevitt (2005) cited below is recommended in addition to achieve a more
balanced view.
Fritzell P, Hagg O, Nordwall A; Swedish Lumbar Spine Study Group (2003)Complica-
tions in lumbar fusion surgery for chronic low back pain: comparison of three surgical
techniques used in a prospective randomized study. A report from the Swedish Lumbar
Spine Study Group. Eur Spine J 12:178 – 189
An overview of all aspects of complications in lumbar fusion, showing a high increase of
complications with instrumentation and further with 360° fusion. In the further course,
several articles were published by the same authors, showing fewer complications like
pseudoarthrosis in the midterm with instrumented 360° fusion.
Inamasu J, Guiot BH (2005) Iatrogenic vertebral artery injury. Acta Neurol Scand
112:349 – 357
This article describes all iatrogenic causes of vertebral artery lesions, including percuta-
neous puncture, treatment options and outcome.
Jansson KA, Nemeth G, Granath F, Blomqvist P (2004)Surgeryforherniationofalum-
bar disc in Sweden between 1987 and 1999.Ananalysisof27 576 operations. J Bone Joint
Surg Br 86:841– 847
This is the best casuistry on complications of surgery for disc herniation. A remarkable
mortality of 0.5% was found in the first 30 days after surgery, which was clearly associ-
ated with increased age.

KraemerR,WildA,HaakH,HerdmannJ,KrauspeR,KraemerJ(2003) Classification
and management of early complications in open lumbar microdiscectomy. Eur Spine J
12:239 – 246
This review article gives a good overview of complications after lumbar microdiscectomy,
with recommendations on treatment.
Lapp MA, B ridwell KH, Lenke LG, Baldus C, Blanke K, Iffrig TM (2001)Prospectiveran-
domization of parenteral hyperalimentation for long fusions with spinal deformity: its
effect on complications and recovery from postoperative malnutrition. Spine 26:809 – 817
This paper emphasizes the importance of sufficient alimentation in avoiding periopera-
tive spinal complications.
1116 Section Complications
Key Articles
LeungYL,GrevittM,HendersonL,SmithJ(2005) Cord monitoring changes and seg-
mental vessel ligation in the “at risk” cord during anterior spinal deformity surgery.
Spine 30:1870 – 1874
A valuable article for identification of patients at risk of paraplegia.
Timberlake GA, Kerstein MD (1995) Venous injury: to repair or ligate, the dilemma
revisited. Am Surg 61:139 – 145
An article on 322 venous lesions, treatment options and the sequelae.
Oderich GS, Panneton JM, Hofer J, Bower TC, Cherry KJ Jr, Sullivan T, Noel AA, Kalra M,
Gloviczki P (2004) Iatrogenic operative injuries of abdominal and pelvic veins: a poten-
tially lethal complication. J Vasc Surg 39:931 – 936
Thisarticlereportsahighmortalityrateaftervenouslesionsandshouldbereadincon-
junction with the article by Timberlake et al.
References
1. Akagi S, Yoshida Y, Kato I, Sasai K, Saito T, Imamura A, Ogawa R (1999) External iliac artery
occlusion in posterior spinal surgery. Spine 24:823–5
2. Andersen T, Christensen FB, Laursen M, Hoy K, Hansen ES, Bunger C (2001) Smoking as a
predictor of negative outcome in lumbar spinal fusion. Spine 26:2623–8
3. Anonymous (2006) Practice advisory for perioperative visual loss associated with spine sur-

gery: A report by the American Society of Anesthesiologists Task Force on Perioperative
Blindness. Anesthesiology 104:1319–28
4. Bademci G, Saygun M, Batay F, Cakmak A, Basar H, Anbarci H, Unal B (2006) Prevalence of
primary tethered cord syndrome associated with occult spinal dysraphism in primary
school children in Turkey. Pediatr Neurosurg 42:4–13
5. Baron EM, Albert TJ (2006) Medical complications of surgical treatment of adult spinal
deformity and how to avoid them. Spine 31:S106–18
6. Belmont PJ, Jr, Kuklo TR, Taylor KF, Freedman BA, Prahinski JR, Kruse RW (2004) Intraspi-
nal anomalies associated with isolated congenital hemivertebra: the role of routine mag-
netic resonance imaging. J Bone Joint Surg Am 86A:1704– 10
7. Ben-David B, Haller G, Taylor P (1987) Anterior spinal fusion complicated by paraplegia. A
case report of a false-negative somatosensory-evoked potential. Spine 12:536–9
8. Bertagnoli R, Yue JJ, Shah RV, Nanieva R, Pfeiffer F, Fenk-Mayer A, Kershaw T, Husted DS
(2005) The treatment of disabling single-level lumbar discogenic low back pain with total
disc arthroplasty utilizing the Prodisc prosthesis: a prospective study with 2-year minimum
follow-up. Spine 30:2230–6
9. Bertalanffy H, Eggert HR (1989) Complications of anterior cervical discectomy without
fusion in 450 consecutive patients. Acta Neurochir (Wien) 99:41–50
10. Beutler WJ, Sweeney CA, Connolly PJ (2001) Recurrent laryngeal nerve injury with anterior
cervical spine surgery – risk with laterality of surgical approach. Spine 26:1337–42
11. Blumenthal S, McAfee PC, Guyer RD, Hochschuler SH, Geisler FH, Holt RT, Garcia R, Jr,
Regan JJ, Ohnmeiss DD (2005) A prospective, randomized, multicenter Food and Drug
Administration investigational device exemptions study of lumbar total disc replacement
with the Charite artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes.
Spine 30:1565–75; discussion E387–91
12. Boardman ND, 3rd, Cofield RH (1999) Neurologic complications of shoulder surgery. Clin
Orthop Relat Res 368:44–53
13. Boockvar JA, Philips MF, Telfeian AE, O’Rourke DM, Marcotte PJ (2001) Results and risk
factors for anterior cervicothoracic junction surgery. J Neurosurg 94:12–7
14. Boos N, Marchesi D, Zuber K, Aebi M (1993) Treatment of severe spondylolisthesis by

reduction and pedicular fixation. A 4–6-year follow-up study. Spine 18:1655–61
15. Brau SA (2002) Mini-open approach to the spine for anterior lumbar interbody fusion:
description of the procedure, results and complications. Spine J 2:216–23
16. Brau SA, Delamarter RB, Schiffman ML, Williams LA, Watkins RG (2004) Vascular injury
during anterior lumbar surgery. Spine J 4:409–12
17. Bungard TJ, Kale-Pradhan PB (1999) Prokinetic agents for the treatment of postoperative
ileus in adults: a review of the literature. Pharmacotherapy 19:416–23
18. Cappell MS, Iacovone FM, Jr (1996) The safety and efficacy of percutaneous endoscopic
gastrostomy after recent myocardial infarction: a study of 28 patients and 40 controls at four
university teaching hospitals. Am J Gastroenterol 91:1599– 603
Treatment of Postoperative Complications Chapter 39 1117
19. Chang YS, Guyer RD, Ohnmeiss DD, Moore S (2003) Case report: intraoperative left com-
mon iliac occlusion in a scheduled 360-degree spinal fusion. Spine 28:E316–9
20. Christodoulou AG, Ploumis A, Terzidis IP, Timiliotou K, Gerogianni N, Spyridis C (2004)
Spleen rupture after surgery in Marfan syndrome scoliosis. J Pediatr Orthop 24:537–40
21. CoeJD,ArletV,DonaldsonW,BervenS,HansonDS,MudiyamR,PerraJH,ShaffreyCI
(2006) Complications in spinal fusion for adolescent idiopathic scoliosis in the new millen-
nium. A report of the Scoliosis Research Society Morbidity and Mortality Committee. Spine
31:345–9
22. Crowther MA, Webb PJ, Eyre-Brook IA (2002) Superior mesenteric artery syndrome follow-
ing surgery for scoliosis. Spine 27:E528–33
23. Dearborn JT, Hu SS, Tribus CB, Bradford DS (1999) Thromboembolic complications after
major thoracolumbar spine surgery. Spine 24:1471–6
24. Delank KS, Delank HW, Konig DP, Popken F, Furderer S, Eysel P (2005) Iatrogenic paraple-
gia in spinal surgery. Arch Orthop Trauma Surg 125:33–41
25. Deutsch L, Testiauti M, Borman T (2001) Simultaneous anterior-posterior thoracolumbar
spine surgery. J Spinal Disord 14:378–84
26. Deyo RA, Cherkin DC, Loeser JD, Bigos SJ, Ciol MA (1992) Morbidity and mortality in asso-
ciation with operations on the lumbar spine. The influence of age, diagnosis, and procedure.
J Bone Joint Surg Am 74:536–43

27. Dick J,Boachie-Adjei O, Wilson M (1992) One-stage versus two-stage anterior and posterior
spinal reconstruction in adults. Comparison of outcomes including nutritional status, com-
plication rates, hospital costs, and other factors. Spine 17:S310–6
28. DimopoulosV,FountasKN,MachinisTG,FeltesC,ChungI,JohnstonK,RobinsonJS,Gri-
gorian A (2005) Postoperative cauda equina syndrome in patients undergoing single-level
lumbar microdiscectomy. Report of two cases. Neurosurg Focus 19:E11
29. DobbsMB,LenkeLG,SzymanskiDA,MorcuendeJA,WeinsteinSL,BridwellKH,Sponseller
PD (2002) Prevalence of neural axis abnormalities in patients with infantile idiopathic scoli-
osis. J Bone Joint Surg Am 84A:2230–4
30. Doita M, Marui T, Nishida K, Kurosaka M, Yoshiya S, Sha N (2002) Anterior spinal artery
syndrome after total spondylectomy of T10, T11, and T12. Clin Orthop Relat Res:175–81
31. Eleraky MA, Llanos C, Sonntag VK (1999) Cervical corpectomy: report of 185 cases and
review of the literature. J Neurosurg 90:35–41
32. Epstein NE (2005) A review of the risks and benefits of differing prophylaxis regimens for
the treatment of deep venous thrombosis and pulmonary embolism in neurosurgery. Surg
Neurol 64:295–301
33. Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L (1995) The surgical and medical
perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar
spine in adults. A review of 1223 procedures. Spine 20:1592–9
34. Faraj AA, Webb JK, Lemberger RJ (1996) Urinary bladder dysfunction following anterior
lumbosacral spine fusion: case report and review of the literature. Eur Spine J 5:121–4
35. Farmer KW, Hammond JW, Queale WS, Keyurapan E, McFarland EG (2007) Shoulder art-
hroplasty versus hip and knee arthroplasties: A comparison of outcomes. Clin Orthop Relat
Res 455:183–189
36. Flinn WR, Sandager GP, Silva MB, Jr, Benjamin ME, Cerullo LJ, Taylor M (1996) Prospective
surveillance for perioperative venous thrombosis. Experience in 2643 patients. Arch Surg
131:472–80
37. Flynn JC, Price CT (1984) Sexual complications of anterior fusion of the lumbar spine. Spine
9:489–92
38. Fritzell P, Hagg O, Nordwall A (2003) Complications in lumbar fusion surgery for chronic

low back pain: comparison of three surgical techniques used in a prospective randomized
study. A report from the Swedish Lumbar Spine Study Group. Eur Spine J 12:178–89
39. Gayer G, Caspi I, Garniek A, Hertz M, Apter S (2002) Perirectal urinoma from ureteral
injury incurred during spinal surgery mimicking rectal perforation on computed tomogra-
phy scan. Spine 27:E451–3
40. Gehri R, Zanetti M, Boos N (2000) Subacute subdural haematoma complicating lumbar
microdiscectomy. J Bone Joint Surg Br 82:1042–5
41. Glassman SD, Alegre G, Carreon L, Dimar JR, Johnson JR (2003) Perioperative complica-
tionsoflumbarinstrumentationandfusioninpatientswithdiabetesmellitus.SpineJ
3:496–501
42. Goodkin R, Laska LL (1998) Vascular and visceral injuries associated with lumbar disc sur-
gery: medicolegal implications. Surg Neurol 49:358–70; discussion 370–2
43. Guigui P, Blamoutier A (2005) [Complications of surgical treatment of spinal deformities: a
prospective multicentric study of 3311 patients]. Rev Chir Orthop Reparatrice Appar Mot
91:314–27
44. Guingrich JA, McDermott JC (2000) Ureteral injury during laparoscopy-assisted anterior
lumbar fusion. Spine 25:1586–8
45. Guzman R, Dubach-Schwizer S, Heini P, Lovblad KO, Kalbermatten D, Schroth G, Remonda
1118 Section Complications
L (2005) Preoperative transarterial embolization of vertebral metastases. Eur Spine J
14:263–8
46. Haaker RG, Senkal M, Kielich T, Kramer J (1997) Percutaneous lumbar discectomy in the
treatment of lumbar discitis. Eur Spine J 6:98–101
47. Hackenberg L, Liljenqvist U, Halm H, Winkelmann W (2001) Occlusion of the left common
iliac artery and consecutive thromboembolism of the left popliteal artery following anterior
lumbar interbody fusion. J Spinal Disord 14:365 –8
48. Hacker RJ, Cauthen JC, Gilbert TJ, Griffith SL (2000) A prospective randomized multicenter
clinical evaluation of an anterior cervical fusion cage. Spine 25:2646–54; discussion 2655
49. Hänggi W, Schwaller K, Mueller MD (1997) Intra- und postoperative Komplikationen bei
der Sectio caesarea. Gynäkologe 30:762–768

50. Harper CM, Ambler G, Edge G (2004) The prognostic value of pre-operative predicted
forced vital capacity in corrective spinal surgery for Duchenne’s muscular dystrophy.
Anaesthesia 59:1160–2
51. Hausmann O, Min K, Boni T, Erni T, Dietz V, Curt A (2003) SSEP analysis in surgery of idio-
pathic scoliosis: the influence of spine deformity and surgical approach. Eur Spine J
12:117–23
52. Henriques T, Olerud C, Petren-Mallmin M, Ahl T (2001) Cauda equina syndrome as a post-
operative complication in five patients operated for lumbar disc herniation. Spine 26:293– 7
53. Hermantin FU, Peters T, Quartararo L, Kambin P (1999) A prospective, randomized study
comparing the results of open discectomy with those of video-assisted arthroscopic micro-
discectomy. J Bone Joint Surg Am 81:958–65
54. Herrera MF, Bauer G, Reynolds F, Wilk RM, Bigliani LU, Levine WN (2002) Infection after
mini-open rotator cuff repair. J Shoulder Elbow Surg 11:605–8
55. Hoff-Olsen P, Wiberg J (2001) Small bowel perforation as a complication of microsurgical
lumbar diskectomy. A case report and brief review of the literature. Am J Forensic Med
Pathol 22:319–21
56. Hood RW, Riseborough EJ, Nehme AM, Micheli LJ, Strand RD, Neuhauser EB (1980) Diaste-
matomyelia and structural spinal deformities. J Bone Joint Surg Am 62:520–8
57. Horan TC, Gaynes RP,Martone WJ, Jarvis WR, Emori TG (1992) CDC definitions of nosoco-
mial surgical site infections, 1992: a modification of CDC definitions of surgical wound
infections. Am J Infect Control 20:271–4
58. Houten JK, Frempong-Boadu AK, Arkovitz MS (2004) Bowel injury as a complication of
microdiscectomy: case report and literature review. J Spinal Disord Tech 17:248–50
59. Hu SS, Fontaine F, Kelly B, Bradford DS (1998) Nutritional depletion in staged spinal recon-
structive surgery. The effect of total parenteral nutrition. Spine 23:1401–5
60. Hurtado-Lopez LM, Zaldivar-Ramirez FR (2002) Risk of injury to the external branch of the
superior laryngeal nerve in thyroidectomy. Laryngoscope 112:626–9
61. Inamasu J, Guiot BH (2005) Iatrogenic vertebral artery injury. Acta Neurol Scand
112:349–57
62. Jansson KA, Nemeth G, Granath F, Blomqvist P (2004) Surgery for herniation of a lumbar

disc in Sweden between 1987 and 1999. An analysis of 27576 operations. J Bone Joint Surg
Br 86:841–7
63. Jinkins JR, Rauch A (1994) Magnetic resonance imaging of entrapment of lumbar nerve
roots in spondylolytic spondylolisthesis. J Bone Joint Surg Am 76:1643–8
64. Johnston CE, 2nd, Happel LT, Jr, Norris R, Burke SW, King AG, Roberts JM (1986) Delayed
paraplegia complicating sublaminar segmental spinal instrumentation. J Bone Joint Surg
Am 68:556–63
65. Kamming D, Clarke S (2005) Postoperative visual loss following prone spinal surgery. Br J
Anaesth 95:257–60
66. Khazim R, Boos N, Webb JK (1998) Progressive thrombotic occlusion of the left common
iliac artery after anterior lumbar interbody fusion. Eur Spine J 7:239–41
67. Korge A, Fischer R, Kluger P, Puhl W (1994) The importance of sonography in the diagnosis
of septic complications following spinal surgery. Eur Spine J 3:303– 7
68. Kraemer R, Wild A, Haak H, Herdmann J, Krauspe R, Kraemer J (2003) Classification and
management of early complications in open lumbar microdiscectomy. Eur Spine J
12:239–46
69. Lapp MA, Bridwell KH, Lenke LG, Baldus C, Blanke K, Iffrig TM (2001) Prospective ran-
domization of parenteral hyperalimentation for long fusions with spinal deformity: its
effect on complications and recovery from postoperative malnutrition. Spine 26:809–17;
discussion 817
70. Lee TC, Yang LC, Chen HJ (1998) Effect of patient position and hypotensive anesthesia on
inferior vena caval pressure. Spine 23:941–7; discussion 947–8
71. Lenke LG, Bridwell KH, Blanke K, Baldus C (1995) Analysis of pulmonary function and
chest cage dimension changes after thoracoplasty in idiopathic scoliosis. Spine 20:1343–50
72.
Leung YL, Grevitt M, Henderson L, Smith J (2005) Cord monitoring changes and segmental
vessel ligation in the “at risk” cord during anterior spinal deformity surgery. Spine 30:1870–4
Treatment of Postoperative Complications Chapter 39 1119
73. Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E, Harris
WH, Poss R, Baron JA (2003) Rates and outcomes of primary and revision total hip replace-

mentintheUnitedStatesmedicarepopulation.JBoneJointSurgAm85A:27–32
74. Marsicano J, Mirovsky Y, Remer S, Bloom N, Neuwirth M (1994) Thrombotic occlusion of
the left common iliac artery after an anterior retroperitoneal approach to the lumbar
spine. Spine 19:357–9
75. Maurice HD, Morley TR (1989) Cauda equina lesions following fusion in situ and decom-
pressive laminectomy for severe spondylolisthesis. Four case reports. Spine 14:214–6
76. McCulloch J, Young PH (1998) Essentials of spinal microsurgery. Lippincott-Raven, Phila-
delphia
77. McDonnell MF, Glassman SD, Dimar JR, 2nd, Puno RM, Johnson JR (1996) Perioperative
complications of anterior procedures on the spine. J Bone Joint Surg Am 78:839–47
78. Melamed H, Harris MB, Awasthi D (2002) Anatomic considerations of superior laryngeal
nerve during anterior cervical spine procedures. Spine 27:E83–6
79. Moore FA, Moore EE, Moore GE, Millikan JS (1984) Risk of splenic salvage after trauma.
Analysis of 200 adults. Am J Surg 148:800–5
80. Muschik M, Luck W, Schlenzka D (2004) Implant removal for late-developing infection
after instrumented posterior spinal fusion for scoliosis: reinstrumentation reduces loss of
correction. A retrospective analysis of 45 cases. Eur Spine J 13:645–51
81. Myers MA, Hamilton SR, Bogosian AJ, Smith CH, Wagner TA (1997) Visual loss as a com-
plication of spine surgery. A review of 37 cases. Spine 22:1325–9
82. Nader R, Alford BT,Nauta HJ, Crow W, vanSonnenberg E, Hadjepavlou AG (2002) Preoper-
ative embolization and intraoperative cryocoagulation as adjuncts in resection of hyper-
vascular lesions of the thoracolumbar spine. J Neurosurg 97:294 –300
83. Naito M, Owen JH, Bridwell KH, Sugioka Y (1992) Effects of distraction on physiologic
integrity of the spinal cord, spinal cord blood flow, and clinical status. Spine 17:1154–8
84. Nguyen DM, Shum-Tim D, Dobell AR, Tchervenkov CI (1995) The management of chylo-
thorax/chylopericardium following pediatric cardiac surgery: a 10-year experience. J Card
Surg 10:302–8
85. Nohara Y, Taneichi H, Ueyama K, Kawahara N, Shiba K, Tokuhashi Y, Tani T, Nakahara S,
Iida T (2004) Nationwide survey on complications of spine surgery in Japan. J Orthop Sci
9:424–33

86. Oderich GS, Panneton JM, Hofer J, Bower TC, Cherry KJ, Jr, Sullivan T, Noel AA, Kalra M,
Gloviczki P (2004) Iatrogenic operative injuries of abdominal and pelvic veins: a poten-
tially lethal complication. J Vasc Surg 39:931–6
87. Olerud C, Jonsson H, Jr, Lofberg AM, Lorelius LE, Sjostrom L (1993) Embolization of spi-
nal metastases reduces peroperative blood loss. 21 patients operated on for renal cell carci-
noma. Acta Orthop Scand 64:9–12
88. Oskouian RJ, Jr, Johnson JP (2002) Vascular complications in anterior thoracolumbar spi-
nal reconstruction. J Neurosurg 96:1–5
89. Parker MJ, Roberts C (2001) Closed suction surgical wound drainage after orthopaedic
surgery. Cochrane Database Syst Rev:CD001825
90. Pelosi L, Lamb J, Grevitt M, Mehdian SM, Webb JK, Blumhardt LD (2002) Combined moni-
toring of motor and somatosensory evoked potentials in orthopaedic spinal surgery. Clin
Neurophysiol 113:1082–91
91. Petraco DM, Spivak JM, Cappadona JG, Kummer FJ, Neuwirth MG (1996) An anatomic
evaluation of L5 nerve stretch in spondylolisthesis reduction. Spine 21:1133–8; discussion
1139
92. Potter BK, Kirk KL, Shah SA, Kuklo TR (2006) Loss of coronal correction following instru-
mentation removal in adolescent idiopathic scoliosis. Spine 31:67–72
93. Ramirez LF, Thisted R (1989) Complications and demographic characteristics of patients
undergoing lumbar discectomy in community hospitals. Neurosurgery 25:226–30; discus-
sion 230–1
94. Raskas DS, Delamarter RB (1997) Occlusion of the left iliac artery after retroperitoneal
exposure of the spine. Clin Orthop Relat Res:86– 9
95. Reissman P, Teoh TA, Cohen SM, Weiss EG, Nogueras JJ, Wexner SD (1995) Is early oral
feeding safe after elective colorectal surgery? A prospective randomized trial. Ann Surg
222:73–7
96. Roberts MP (1988) Complications of lumbar disc surgery. Spinal Surg 2:13–19
97. Robertson ML, Steward DL, Gluckman JL, Welge J (2004) Continuous laryngeal nerve
integrity monitoring during thyroidectomy: does it reduce risk of injury? Otolaryngol
Head Neck Surg 131:596–600

98. Rompe JD, Eysel P, Zollner J, Heine J (1999) [Intra- and postoperative risk analysis after
lumbar intervertebral disk operation]. Z Orthop Ihre Grenzgeb 137:201–5
99. Sasso RC, Kenneth Burkus J, LeHuec JC (2003) Retrograde ejaculation after anterior lum-
bar interbody fusion: transperitoneal versus retroperitoneal exposure. Spine 28:1023–6
100. Schilder JM, Hurteau JA, Look KY, Moore DH, Raff G, Stehman FB, Sutton GP (1997) A pro-
1120 Section Complications
spective controlled trial of early postoperative oral intake following major abdominal
gynecologic surgery. Gynecol Oncol 67:235–40
101. Schinsky MF, Macaulay W, Parks ML, Kiernan H, Nercessian OA (2001) Nerve injury after
primary total knee arthroplasty. J Arthroplasty 16:1048–54
102. Schmalzried TP, Amstutz HC, Dorey FJ (1991) Nerve palsy associated with total hip
replacement. Risk factors and prognosis. J Bone Joint Surg Am 73:1074–80
103. Schoenecker PL, Cole HO, Herring JA, Capelli AM, Bradford DS (1990) Cauda equina syn-
drome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction. J
Bone Joint Surg Am 72:369–77
104. Scuderi GJ, Vaccaro AR, Brusovanik GV, Kwon BK, Berta SC (2004) Conjoined lumbar
nerve roots: a frequently underappreciated congenital abnormality. J Spinal Disord Tech
17:86–93
105. Shah MA, Albright MB, Vogt MT, Moreland MS (2003) Superior mesenteric artery syn-
drome in scoliosis surgery: weight percentile for height as an indicator of risk. J Pediatr
Orthop 23:665–8
106. Sperling JW, Kozak TK, Hanssen AD, Cofield RH (2001) Infection after shoulder arthropla-
sty. Clin Orthop Relat Res:206–16
107. Stockl B, Wimmer C, Innerhofer P, Kofler M, Behensky H (2005) Delayed anterior spinal
artery syndrome following posterior scoliosis correction. Eur Spine J 14:906–9
108. Strahm C, Min K, Boos N, Ruetsch Y, Curt A (2003) Reliability of perioperative SSEP
recordings in spine surgery. Spinal Cord 41:483–9
109. Szoke G, Lipton G, Miller F, Dabney K (1998) Wound infection after spinal fusion in chil-
dren with cerebral palsy. J Pediatr Orthop 18:727–33
110. Takeuchi K, Yokoyama T, Aburakawa S, Itabashi T, Toh S (2005) Anatomic study of the

semispinalis cervicis for reattachment during laminoplasty. Clin Orthop Relat Res:126–31
111. Timberlake GA, Kerstein MD (1995) Venous injury: to repair or ligate, the dilemma revis-
ited. Am Surg 61:139–45
112. Torossian A, Schmidt J, Schaffartzik W, Wulf H (2006) Loss of vision after non-ophthalmic
surgery: Systematic review of the literature on incidence, pathogenesis, treatment and pre-
vention. Anaesthesist 55:457–464
113. Tsai YD, Yu PC, Lee TC, Chen HS, Wang SH, Kuo YL (2001) Superior rectal artery injury
following lumbar disc surgery. Case report. J Neurosurg 95:108–10
114. Tsuzuki N, Hirabayashi S, Abe R, Saiki K (2001) Staged spinal cord decompression through
posterior approach for thoracic myelopathy caused by ossification of posterior longitudi-
nal ligament. Spine 26:1623–30
115. Wazeka AN, DiMaio MF, Boachie-Adjei O (2004) Outcome of pediatric patients with severe
restrictive lung disease following reconstructive spine surgery. Spine 29:528–34; discus-
sion 535
116. Wilkin TD, Kraus MA, Lane KA, Trerotola SO (2003) Internal jugular vein thrombosis
associated with hemodialysis catheters. Radiology 228:697–700
117. Wilson AP, Gibbons C, Reeves BC, Hodgson B, Liu M, Plummer D, Krukowski ZH, Bruce J,
Wilson J, Pearson A (2004) Surgical wound infection as a performance indicator: agree-
ment of common definitions of wound infection in 4773 patients. BMJ 329:720
118. Winter RB, Lonstein JE, Denis F, Leonard AS, Garamella JJ (1996) Paraplegia resulting
from vessel ligation. Spine 21:1232–3; discussion 1233–4
119. Wright N (2005) Single-surgeon simultaneous versus staged anterior and posterior spinal
reconstruction: a comparative study. J Spinal Disord Tech 18 Suppl:S48–57
120. Wright NM, Lauryssen C (1998) Vertebral artery injury in C1–2 transarticular screw fixa-
tion: results of a survey of the AANS/CNS section on disorders of the spine and peripheral
nerves. American Association of Neurological Surgeons/Congress of Neurological Sur-
geons. J Neurosurg 88:634–40
121. Yarbrough DE, Thompson GB, Kasperbauer JL, Harper CM, Grant CS (2004) Intraopera-
tive electromyographic monitoring of the recurrent laryngeal nerve in reoperative thyroid
and parathyroid surgery. Surgery 136:1107–15

Treatment of Postoperative Complications Chapter 39 1121
40
Outcome Assessment
in Spinal Surgery
Mathias Haefeli, Norbert Boos
Core Messages
✔
The evaluation of treatment modalities for spi-
nal disorders by self-administered question-
naires has entered into clinical practice
✔
Functional and psychosocial aspects often
exhibit a closer correlation with fair or poor
outcome after spinal surgery than organ-spe-
cific symptoms and morphological alterations
and must therefore be evaluated in outcome
research
✔
The main subjects addressed by outcome tools
are pain, disability, health-related quality of life
and work status
✔
For more thorough investigations, psychosocial
aspects, work-related parameters and fear
avoidance behavior should additionally be
assessed
✔
There are several standardized and validated
questionnaires available
✔

Current research is trying to facilitate data
assessment by developing short but reliable
instruments
General Concepts of Outcome Assessment
The evaluation of treatment modalities in spinal orders by self-administered
assessment tools has become standard in most institutions. In many fields of
medicine and particularly in spinal surgery, it has become evident that treatment
outcome is influenced by a large variety of non-morphological factors [100]. Psy-
chosocialaspectsandwork-relatedfactorsoftenexhibitahigherpredictivevalue
than pathomorphological and surgical aspects [47]. Therefore, it has become
apparent that a meaningful outcome assessment should consider most of these
confounding variables, which, however, is not always possible to achieve in a
busy clinical practice. The minimal data set that should be collected consists of:
pain
disability
quality of life
work status
Several criteria should be considered when data assessment is performed by self-
rating questionnair es:
comparability
validity
availability
scale characteristics
When a comparison between treatment groups is chosen in a study, the criteria
ofcomparabilityofaquestionnairemustbedefined.Iftheresultsaretobecom-
Outcome Assessment Section 1123
pared with a control group out of the literature, an identical questionnaire must
be used.
Validity[2]isthedegreetowhichaninstrumentmeasureswhatitisintended
to measure. It is the most important quality of a questionnaire and there are dif-

ferent types of validity. A questionnaire ideal ly should fulfill:
content validity, i.e. the extent to which the instruments include the domain
of the target phenomenon
criterion validity,i.e.extentofagreementwhencomparingwitha“gold
standard”
construct validity, i.e. extent to which the instrument corresponds to theo-
retical concepts of the target phenomenon
Most of the questionnaires are developed for the English language. If these tools
are used in non-English speaking countries, these versions should ideally be
translated and validated first for the used language (availability). Several rules
should be considered in this process of cross-cultural adaptation [13]. According
to this, such a process should start with at least two forward translations into the
target language. In a second step a synthesis of the two translations should be
done before performing at least two back translations in the next step. After a
consolidation of all versions of the instruments resulting from the first three
Table 1. Outcome tools in spinal surgery
Topic Tool Available languages
(validated versions only)
Pain VAS/GRS/NRS/VRS
Disability RMDQ English [131]
French [38]
German [156]
Greek [24]
Portuguese [115]
Spanish [88]
Swedish [82]
Turkish [90]
ODI English [50]
Finnish [63]
French [157]

German [11, 101, 102]
Greek [24]
NASS-Q English [39]
German [123]
Italian [119]
FAQH German [86]
NDI English [145]
French [157]
Swedish [3]
NPDI English [154]
French [157]
Turkish [20]
Quality of life WHOQOL-100/-Bref www.who.int
SF-36/-12/-8 www.sf36.com
EQ-5D www.euroqol.org
SRS-22/-30 English: www.srs.org
Spanish [10]
Fear avoidance behavior FABQ English [149]
German [121, 138]
Core item tools Low back pain English [41]
German [99]
Neck pain English [155]
1124 Section Outcome Assessment